Rural value-based care initiative faces funding cliff


The smallest and most rural healthcare providers will soon lose access to help in shifting to value-based care unless Congress steps in.

Over the past five years, rural providers with fewer than 15 clinicians have been increasingly encouraged to participate in the Merit-based Incentive Payment System value-based payment program that provides financial bonuses or penalties. Participating providers must submit data on costs, outcomes, quality and interoperability or risk getting dinged with cuts to Medicare payments. This year, that amounts to a 9% decrease for not taking part in the program.

When Congress created MIPS in 2015, lawmakers also gave the Centers for Medicare and Medicaid Services $100 million to create the Small, Underserved, and Rural Support program to help these providers wade through what measures to report and how to keep current with changes to MIPS. But starting Feb. 15, the money is set to run out.

CMS notified providers this week that the Small, Underserved, and Rural Support program would soon sunset. Technical assistance contractors have been cautioning providers for months that they would have to largely manage the transition to MIPS on their own once the funding disappears.

“In these smaller practices, this is just another hat that someone in the organization wears, typically an office manager or a billing person. And it’s very different from larger organizations because when you have the time to be 100% dedicated to this program, you have a much easier time staying on top of all of the details,” said Candy Hanson, program manager at quality improvement nonprofit Stratis Health, a SURS subcontractor.

“We’ve got some practices that will probably wish they had us to double check their work,” said Megan Housley, assistant managing director at the University of Kentucky Regional Extension Center, a SURS subcontractor. “Then we’ve got others that are kind of clueless on their own that I am really worried about. They’re heavy utilizers of us each year.”

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Small practices have seen the most MIPS penalties. Of the 1 million clinicians who participated in the 2019 performance year, about 95% received bonuses. Almost 99% of groups with more than 99 providers received bonuses. That compares to almost 90% of groups with two to 15 providers and almost 64% of solo providers that received bonuses.

Under MIPS, providers choose from among a wide range of measures within each category based on their strengths. But sifting through data and figuring out what exactly should be reported is complicated. That’s where SURS contractors come in. Of the 136,448 small providers in 2019 MIPS program, about 99,000 received technical assistance, according to the Government Accountability Office.

That consulting can range from guiding providers on how to gather relevant data and chose the measures that reflect best on a practice to basic education about the purpose of value-based care itself.

Hanson recalled an optometrist who initially was just going to take the Medicare cut for his practice not participating in MIPS. “He didn’t think that there was going to be value in this, yet not only did we convince him to report, but they’ve been one of the top performers ever since,” Hanson said. “We also provided education to all of his staff to understand the workflow of collecting the data and reporting because MIPS does require, especially in small organizations, for everyone to understand the workflow to be successful.”

A coalition including the American Medical Association, the American College of Physicians, the Medical Group Management Association and the National Partnership for Women and Families asked Congress in late November to extend the program.

A Small, Underserved, and Rural Support program extension could be wrapped into spending bills early next year, said Claire Ernst, the MGMA’s director of government affairs.

“The frustrations that larger practices face with the MIPS program, I think that smaller practices feel it just as much, if not more,” Ernst said. “Any sort of assistance that can help them comply in this incredibly complicated and always changing program is really critical for their success.”

Yet SURS’ effectiveness at helping small, rural providers adapt to MIPS is unclear and there is no research on how well contractors performed. MACRA, the law that created both MIPS and SURS, didn’t instruct CMS to evaluate the results of the financial support or its implications for MIPS. SURS contractors have achieved a 99% average annual clinician satisfaction rate for technical assistance, based on an average of 19,281 responses, a CMS spokesperson wrote in an email.

“The broader question is: How useful is this program?” said Peter Mendel, a senior sociologist at the RAND Corp. When RAND studied MIPS in 2018, the consulting firm gathered feedback from participating providers indicating they viewed the initiative as onerous. “The program still required so much work on the part of physicians that even having that support did not relieve the burden for participating that much,” he said.

Providers have until March to turn in this year’s data, the results of which will be seen in their 2023 payment rates. In March 2023, the CMS Quality Payment Program Service Center will be available to answer basic questions and address more complex scenarios, the agency said in its announcement about the expiration of SURS funding.



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